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THE FLOATING CLAVICLE DOLFI AND HERSCOVICI JR, NECK G. T. W. FIENNES, R#{228}tisches Kantons mid-clavicular IPSILATERAL SCAPULAR ALBERIC From In ipsilateral SHOULDER: and FRACFURES M. ALLG#{246}WER, Regionalspital, THOMAS P. RUED! Switzerland and scapular-neck fractures, the mechanical stability of the suspensory and the weight of the arm pull the glenoid fragment distally and we recommend internal fixation of the fractured clavicle by a plate patients with this unusual injury; all achieved an excellent functional result structures is disrupted and muscle forces anteromedially. To prevent late deformity and screws. We treated without deformity. seven Fractures constitute of the scapula are high-energy 1% of all fractures, and involving the shoulder (Imatani injuries ; they of fractures 5% 1975; McGahan, berger Simpson 1975; and treatment in injuries scapula, is not but this usually of the so when produces clavicle both MATERIALS good or or of the bones Christ 1975; Hardegger, Rab and Dublin 1980). Clavicle fractures are common, usually being caused by a fall or a blow to the tip of the shoulder. Conservative excellent results Tscherne and Weber 1984). are AND METHODS We observed 1 1,004 trauma patients from January 1979 to April 1990; 145 (1 .3%) had clavicle fractures and 68 injured simultaneously. Table I. Definitions and ratings of the functional examination ANATOMY The glenohumeral joint Score allows the arm a wide range movement tures must movements. in all directions, and the surrounding provide stability without constraining The capsule and the glenohumeral, clavicular, acromioclavicular ments rotator which involving the clavicle When there help muscles the is a fracture the scapula and becomes unstable fragment to maintain and the (Fig. acting distally on and liga- pectoralis and and stabilising stability scapula. of both the surgical humerus pull anteromedially Subjective Pain None; requires no medication Mild ; occurs with severe stress, rarely requires medication, i.e., less than twice a week Moderate ; occurs with prolonged activity, may have changed jobs or quit certain sports, requires medication two to five times a week Severe ; limits all activities, pain at rest, requires medication more than five times a week neck (Ganz of fracture arm and the glenoid and Noes- Life-style Occupation and sport activity level equal to pre-injury Injury caused occupational change or limited certain Correspondence Orthopaedic 33617-2011, © 1992 should Institute, USA. be 4175 sent East R#{228}tisches Kantons British Editorial Society ofBone 0301-620X/92/3323 $2.00 J Bone Joint Surg [Br] 1992; 74-B : 362-4. 362 state sport Can only perform assistance Total disability Physical examination Range of abduction activities ofdaily living or needs minimal and D. Herscovici at Avenue, Tampa, and Joint 3 2 Surgery RegionFlorida Florida 4 3 4 3 2 Muscle strength Grade 5 Grade 4 Grade 3 Grade 2 or less Functional Excellent Good 2 or flexion 120#{176} 90#{176} to 120#{176} 45#{176} to 90#{176} <45#{176} to Dr Fowler 4 activities > D. Herscovici Jr, DO, AO Fellow A. G. T. W. Fiennes, MS, FRCS M. Allgower, Trauma Scholar T. P. ROedi, MD, FACS, Professor Department of Trauma and Surgery, alspital, Chur CH-7000, Switzerland. examination in fractures clavicle, the scapular 1) and the weight of the the structhese coraco- coracohumeral along with the deltoid, trapezius, cuff muscles are the suspensory structures the and of 4 3 2 rating 13 to 16 9 to 12 5to8 4 or less Fair Poor THE JOURNAL OF BONE AND JOINT SURGERY THE FLOATING Fig. Figure 1a - Unstable Stable fracture - :IPSILATERAL SHOULDER fracture pattern CLAVICLE AND SCAPULAR NECK la FRACTURES Fig. of the scapular neck with with an ipsilateral clavicle an intact fracture. clavicle and 363 lb coracoclavicular ligaments. Figure 1b were started within three to five days. Patients treated nonoperatively also used a sling and started active exercises as soon as their associated injuries allowed. Review. At review, about pain, strength and were the were and muscle as having uninvolved with was were Anteroposterior mid-shaft clavicle view of the fractures. (0.6%) had scapular (0. 15%) with fractures of these had patients Patients taken the results of the deformities the overall or were using clavicle but the functional rating. 2 showing fractures. of both ipsilateral scapular and (Hardegger have Seven patients had been treated surgically and all were rated as excellent at review. Five had no pain and two There were 17 patients bones, but only 11 (0.10%) clavicular fracture of these as RESULTS a mid-shaft scapular-neck Two scapula Muscle abduction of motion fair or poor and the scapula to identify residual radiological findings did not affect Fig. range recorded. good, criteria in Table I. Follow-up radiographs and shoulder the lowest strength excellent, by questionnaire life-style. in flexion the function weakest asked present ofmovement using The rated the range recorded, control. patients medication and an et a! 1984) since died. We have had pain pain ipsilateral (Fig. 2). only control previous on exertion. and None only two medication failed to return for to their life-style. Of the two patients reviewed required had treated conservatively one had a the remaining nine patients, one by telephone interview only. There were five men and four women with a mean good and one a poor result. Both, however, had suffered severe associated injuries which was the reason for nonoperative treatment. One had an ipsilateral hemi- age of 29.6 years (17 to 58). Six patients had the left side. All the fractures were closed. plegia follow-up was had caused been Treatment. surgically, either 48.5 months by traffic (2 to 132). 3.5 mm AO arm was placed VOL. 74-B, No. AO 3, MAY in a sling 1992 who had been of the clavicle dynamic reconstruction of the injuries accidents. In those patients primary stabilisation a 3.5 mm Most the injury on The average compression plate. for comfort treated was by plate or a Postoperatively, and active the exercises and a sequel his the other breathing, his activities. All the fractures tively treated showed (Fig. 3). but strength. greater had pain, not to lung and thoracic-wall All ability to sleep united. one in his shoulder, injuries, The and two ‘drooping’ oftheir patient obtained which his but as affected recreational patients injured grade-S conservashoulders muscle Seven patients achieved a range of movement than 1350 in both abduction and flexion, as 364 D. HERSCOVICI compared with 160#{176} on the uninjured side. chest-wall injuries limited movement and abduction in one patient and attributed to his recent There were w. A. G. T. JR, FIENNES, M. ALLG#{246}WER, T. P. RUEDI Associated to l250 in another in flexion to 1 iSO, surgery. no surgicalcomplications in the operated group. Four patients complained of minor discomfort when carrying knapsacks or skis but this was always relieved when the load was adjusted. All the surgically treated patients were pleased with the appearance of the injured shoulder. DISCUSSION Although uncommon, fractures of the scapula are usually caused by higher energy injuries than those ofthe clavicle. Both, however, heal well with conservative care. Surgery Drooping fixation is traditionally surgeons fixation both reserved the clavicle clavicular for and fracture may Johnston injuries involving However, be clinically fracture may be missed Khan and Lucas 1978; and certain scapula. obvious only the ; the scapular et al 1984; Aulicino et a! 1986; Jupiter and Leffert 1987; R#{252}ediand Chapman 1988). This may result in unnecessary disability due to distal and anteromedial displacement of the fracture of the scapular neck. There have been few descriptions of this several reasons. First, the diagnosis secondly, a failure to understand anatomy may lead to injury for may be missed; the pathological undertreatment ; thirdly not of injuries culoskeletal neck divert the clavicle If the internal as soon conservatively, without with the technique of ; and lastly the severity may recommend of the views. then treated attention from internal of the the mus- damage. We graphs of a patient clavicle. are familiar these bones associated (Rowe 1968 ; Imatani 1975 ; Ali McGahan et al 1980; Wilkins 1983 ; Hardegger left shoulder of the fractured injury of anteroposterior scapula, pattern fixation as possible use and and described here of the clavicle to prevent radio- trans-scapular should malunion is present, be performed of the scapular- fracture. We wish to thank all article. No benefits from a commercial this article. Ms Anne Palmer for her help in the preparation of this in any party form have been related directly received or will be received or indirectly to the subject of REFERENCES All Khan MA, Lucas HK. clavicle. Injury 1978; AUIICInO PL, articular fixation. Ganz R, Noesberger Simpson fractures. RJ. Fractures Jupiter JB, Leffert 1987 LA, Weber J Bone Joint of the scapula. RD. ; 69-A Nonunion :753-60. ofthe middle third of the McGahan JP, Rab GT, Dublin A. Fractures of the scapula. J Trauma 1980; 20 :880-3. Williamson by open B. Die Behandlung 1975 ; 126:59-62. Imatani [Am] of fractures Relnert C, Kornberg M, glenoid fractures treated J Trauma 1986; 26:1137-41. Unfa//heilkd Hardegger FH, scapular Plating 9:263-7. der BG. Surg intrainternal Scapula-Frakturen. The [Br] J Trauma of the S. Displaced reduction and 1975 clavicle. 66-B C/inOrzhop Hefte operative 1984; Rowe CR. An atlas ofanatomy treatment ; 15:473-8. Joint ofmidclavicular fractures. T, Chapman MW. Operative orthopaedics. 1988:197-202. Fractures of the Philadelphia, scapula and clavicle. etc : JB Lippincott In: Co, Operative Therapie 1975 ; 126:52-9. der of :725-31. J Bone Ruedi und treatment 1968; 58:29-42. Surg Tscberne H, Christ SchulterblattbrUche. M. Wilkins RM. Ununited 1983 ; 65-A :773-8. Joint RM, Surg Johnston [Am] Konservative and Hefte Unfa//heilkd fractures of the clavicle. J Bone I THE JOURNAL OF BONE AND JOINT SURGERY